Care delivered by hospitalists has gone solidly main-stream. There are currently more than 44,000 practicing hospitalists in the U.S., up dramatically from fewer than 1,000 in the mid-1990s. Approximately 72 percent of U.S. hospitals now employ or contract for hospitalist services.

Multiple studies show that these hospitalists deliver real value. A 2009 study, co-written by Wharton professor Guy David and published in the journal Medical Care Research and Review, compared hospitalists with medical residents on various measures, such as diagnostic efficiency, appropriateness of medical tests ordered and impact on lengths of stay. The study found that on average, hospitalists delivered superior performance across all categories. Yet while the majority of hospitals employ them, only one in 15 internal medicine students specialize as hospitalists. With demand outpacing supply, overall hospitalist compensation has more than doubled in the last 15 years as hospitals struggle to recruit and retain them. This is one group that can be selective regarding choice of employer.

The Wharton study noted that the reason hospitalists deliver high value is that they are always there, taking care of patients around-the-clock for unprecedented efficiencies. “They can go on rounds at five in the afternoon, which means the patient can be discharged the next morning, or even the same night,” said co-author Professor David (source: knowledge@wharton). That positive factor, however, has a negative side when it comes to telehospitalist recruitment and retention.

The issue of nighttime coverage
The nighttime coverage Professor David referred to includes late-evening and overnight admissions plus any need for physician attention that arises at those times, and it contributes demonstrably to improved patient outcomes. At the same time, the extension of hospitalist care to nighttime coverage puts smaller, often rural hospitals, at a significant operational disadvantage compared to their larger urban counterparts.

Large hospitals with high patient volumes typically can justify the hiring of fulltime nocturnists, who command a higher salary than typical hospitalists of similar qualifications and experience in exchange for dedicated overnight duty. In this scenario, most of the hospitalists on staff work a typical dayshift position and do not have to share in night coverage. Smaller, often rural hospitals do not have a comparable need for full-time physician coverage at night and can’t justify the expense of a nocturnist who would inevitably prove to be underutilized. For these hospitals, night coverage must be spread among those whose primary responsibility is delivering daytime care.

For smaller hospitals, two unfavorable alternatives to full-time nocturnists
Assigning night coverage to general hospitalists means they must accept one of two requirements: shift rotations or overnight call duty. Shift rotations are often preferred by hospitals with nighttime care needs sufficient to require around-the-clock coverage, but with insufficient resources to hire more costly dedicated nocturnists. These rotations require physicians who may work 14 days of 12-hour shifts each month to perform some of those rotations at night, impacting sleep patterns and interfering with home life. This work pattern can lead to burnout for existing staff, and hinders attempts to recruit and retain hospitalists who can accept employment with no such drawbacks at larger hospitals.

Small hospitals with less predictable needs for nighttime coverage usually opt for overnight call duty. This is also disruptive to sleep patterns and home life, with the added drawback of unpredictability. Calls can come at any time of the night – and frequently do – requiring the physician to awaken and make a best effort at care provision while on the phone with an on-site nurse, often resulting in a drive to the hospital. In addition to causing burnout and hindering recruitment and retention, this practice may cause stable patients admitted at night to not be seen by a physician until the next morning.

A third alternative to nocturnists: Nighttime telehospitalists
Unable to deliver around-the-clock hospitalist care comparable to larger hospitals, and with the hospitalists they employ put at a disadvantage for work/life balance compared to their peers in larger hospitals, smaller hospitals need an effective alternative to night rotations and night call duty. Increasingly, that alternative is nighttime telehospitalist service.

Telehospitalist care is a form of telemedicine created specifically for inpatient settings. It leverages nursing staff for hands-on attention while a hospitalist working off-site delivers clinical decision-making, directing a robotic camera and interacting with nurse and patient via two-way audio-video. Telehospitalists can access EMRs and diagnostic scans, communicate face-to-face with patients to discern needs and symptoms, and make effective diagnoses and prescribe treatments.

When it’s time for telehospitalist care, instead of being physically there at the patient’s bedside, the physician is “beamed in” to give patients the expert care they need, immediately. When not needed at a particular location, the telehospitalist can turn to patients at other hospitals, creating cost savings through resource sharing.

While the advantages of telehospitalist coverage extend to other specialty areas, for example, giving a smaller hospital access to a neurologist, it provides a triple bonus in nighttime hospitalist coverage. Hospitals gain affordable access to the level of around-the-clock physician support they require without having to staff a full-time nocturnist or ask physicians who administer care during the day to provide night coverage. Patients gain access to immediate, expert care around the clock, from admission to discharge. Subsequently, hospitalists with ample options for employment at larger hospitals that require no night coverage can enjoy the same work/life balance at a smaller hospital – which helps to level the playing field for those hospitals in physician recruitment and retention, as well as in care delivery.